Nurse Alliance Disaster Relief Form
**As of October 19th, 2018, no additional volunteers are needed to assist with Hurricane Michael relief efforts. We will keep you posted as more needs arise!**
SEIU Healthcare PA Volunteer Informatin Form for those interested in volunteering for diaster relief efforts
Full legal name as it appears on your government ID
Your answer
Local Union and State
Your answer
Employer (name of the hospital, nursing home or state facility where you work)
Your answer
Length of time you might be able to volunteer
Your answer
Do you speak any language other than English? (If so, which language)
Your answer
Vaccinations in order? Standard Childhood and Adult Immunizations plus Tetanus, Hepatitis A & B, (Most health care workers have these) and Yellow fever?
Do you have disaster relief experience?
If you answered "yes" above, which country?
Your answer
Current job title
Your answer
License Number and state
Your answer
Area of expertise (such as ER, OR, Critical Care, Ortho, Tele, post-surgical, wound management, mental health, OB, prehospital , flight team, pediatrics? etc)
Your answer
Skills/Hobby not related to job such as carpenter, heavy equipment operator, agriculture, animal care, childcare, sign language, horticulture, anything you can think of.
Your answer
Date of Birth for flight purposes
MM
/
DD
/
YYYY
Cell phone number
Your answer
Personal email address
Your answer
Home address
Your answer
Nearest local airport
Your answer
Allergies / Personal health information
Your answer
Emergency Contact name (at least one is required) *
Your answer
Emergency contact person phone # *
Your answer
Emergency Contact Relationship *
Your answer
Emergency Contact Phone 2
Your answer
Emergency Contact Email *
Your answer
Emergency Contact name (secondary). Include relationship, phone number and email
Your answer
Health Insurance Provider
Your answer
Additional comments: Experiences in nursing, with disaster relief, mission trips, military experience, or any other life experiences. Such as are you a handyman or woman, scout leader, all kinds of life skills may be appropriate so please elaborate
Your answer
Why do you want to be a disaster response team member?
Your answer
List any persons of influence you may know, who may help with funding, share a plane, sports figure, elected official, business owner, etc
Your answer
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